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~ � Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> - ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) McDonald Septic Tank Service Address 4645 HILDRETH Lane <br /> a Owner <br /> T. R. McDonald Address Same <br /> J Firm Partners, Addresses and Telephone Numbers } I <br /> aBusiness Telephone No. 931-0497 Emergency Telephone No. 9572-7 <br /> Contractor Licence No. 308171 <br /> L Applicants Name (Print) T• R. McDonald Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liczase Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address 1 <br /> 2. ❑ PUMPER YARD #*. <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> I <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ' <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT O <br /> Job Address/Location <br /> Owner Address <br /> 11 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING IELD C] SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 - <br /> SIZE: ❑ Less Than 1,000 Sq. FL, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,-Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rulesand regulate of the San Joaquin Lo I Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br />� Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> i BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> f <br /> FEE 4 46 <br /> LESS CA-/ <br /> F <br /> PLUS l <br /> PENALTY i r <br /> OTHER <br /> OTHER d t <br /> Received by Date Receipt No. Permit � -- I -TssuandeFlate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,.CA 95201 , <br />